St Josephs Primary School, Warrnambool
Permission for the Administration of Medication
Students Full Name
*
First Name
Last Name
Medical Condition:
*
Name of Medication 1 to be administered (as per prescription or packaging):
*
Date or date range for Medication 1 to be given:
*
Dosage to be given (Medication 1):
*
Time to be given to student (Medication 1):
*
Name of Medication 2 to be administered (as per prescription or packaging) {If more than one medication is required}:
Date or date range for Medication 2 to be given:
Dosage to be given (Medication 2):
Time to be given (Medication 2):
Doctor who prescribed medication/s:
Please ensure ALL medication delivered to the school:
Is in its original packaging
The pharmacy label matches the information included in this form
Do you want any unused medication to be returned to you?
Yes
No
Parent or Guardians Full Name:
*
First Name
Last Name
Parent Contact Number:
*
-
Area Code
Phone Number
Parent Contact email address:
example@example.com
Parent Signature:
Continue
Continue
Should be Empty: